List Archives

Tue Jul 3 16:12:11 BST 2007

Thank you all.  

She is already on anticoagulation.  The lesion was too
high to be stented as per vascular / interventional
radiology.  We did consider an angiogram to be sure of
the dissection, but our neuroradiologists were so sure
that they did not think it was needed.  I will try to
upload the images if I can.  The use of a doppler of
the middle cerebral artery to look for emboli is
intriguing and I will talk to our radiologists to see
if they have any experience with it.  

Sanjay

--- Ronald Gross <Rgross at harthosp.org> wrote:

> Sanjay,
> 
> I would think that at this point in her care,
> anticoagulation would not
> be contraindicated because all of her potential
> bleeding sites have been
> dealt with in one way or another.  In fact, your
> choices here would be
> anticoagulation or stenting, and the latter would
> depend on the location
> of the lesion.  If it were me and I were 30 (I can
> wish, can't I ???) I
> would probably choose the coumadin for 3 months -
> and be VERY careful!
> 
> Just my 2 cents,
> Ron
> 
> >>> Sanjay Gupta MD <sanjaygupta99_91 at yahoo.com>
> 7/2/2007 4:03 PM >>>
> Dear Trauma List members,
> 
> I have a difficult problem.  
> 
> 30 years female patient. Motor vehicle collision. 
> Pelvic fracture, spleen rupture, bladder rupture,
> small subarachnoid bleed.  Hypotensive at arrival
> -underwent ex-lap, splenectomy, bladder repair.  Did
> well with these injuries, but remained disoriented
> after extubation for a long time.  One of our
> partners
> called a neurology evaluation, who as a part of
> their
> evaluation ordered a CT angiogram of the head which
> revealed a high dissection of the left carotid
> artery.
>  The head CT is otherwise normal. Radiologist is
> sure
> it is there.  The patient moves both sides of her
> bodies.  The angiogram was done on the 12th day
> after
> trauma.  No obvious focal deficits - sensory or
> motor.
>  Her sensorium is gradually improving.  However,
> neurosurgeons and neurologists want to anticoagulate
> the patient for a minimum of 3 months.  I am not
> sure
> if this will help.
> 
> 
> Any input would be appreciated.  
> 
> 
> 
> Thanks
> 
> Sanjay
> 
> 
> 
> 
> 
> --- "Hardcastle, Tim, Dr <tch at sun.ac.za>"
> <tch at sun.ac.za> wrote:
> 
> > Jose
> > 
> > I can't talk about level of evidence on this one -
> > only personal and institutional experience, namely
> > that most children who present frankly hypotensive
> > for age, without adequate fluids (we try to use
> > blood products early) to at least get them back to
> a
> > reasonable baseline pressure (70+2Xage) have died,
> > despite rapid assessment and rapid surgical
> > intervention. We have seen a progressive
> tachycardia
> > till the point of "no-return". The challenge with
> > the small child is not the fact that they are
> > hypotensive, rather the answer to whether the "are
> > bleeding" or "have bled". The former group -
> > permissive hypovolaemia - no problem -  get them
> to
> > definitive surgical care - still high mortality.
> The
> > latter group - surgical intervention may do more
> > harm than good; one would rather fully resus and
> > investigate intensively with imaging once stable.
> > The challenge is that the latter group is the vast
> > majority.
> > 
> > So in summary, it is about the decision as to
> > whether surgery is the management of choice or
> > rather investigae and manage SNOM, that dictates
> the
> > need for formal resuscitation to normalish values.
> > Again this is for BLUNT trauma, not penetrating
> > trauma.
> > 
> > Tim
> > Dr T C Hardcastle
> > M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> > Senior Surgeon / Senior Lecturer: Surgery (Trauma
> > and ICU)
> > ATLS  instructor and DSTC Cape Town Course
> Director
> > Intern program Coordinator: Surgery
> > M.Med (Emergency Medicine) Executive Committee
> > member
> > Clinical Head (Director): Diana Princess of Wales
> > Trauma Unit
> > Division of Surgery (General) Room 4064
> > Department of Surgical Sciences
> > Tygerberg Hospital / University of Stellenbosch
> > PO Box 19063
> > Tygerberg 7505
> > Western Cape
> > South Africa
> > e-mail: tch at sun.ac.za 
> > Cell: +27824681615
> > Office: +27219389281 or 4911 pager 0302
> > 
> > 
> > 
> > 
> > 
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org 
> > [mailto:trauma-list-bounces at trauma.org]On Behalf
> Of
> > JOSE SUAREZ PELAEZ
> > Sent: Thursday, June 14, 2007 2:33 PM
> > To: Trauma & Critical Care mailing list
> > Subject: Re: Pre-hospital fluid therapy.
> > 
> > 
> > Dear Dr Hardcastle,
> > 
> > 
> > 
> > Thank you for your comments.
> > 
> > 
> > 
> > It is true that when a certain hypovelemia exists,
> > increases within specific 
> > limits in cardiac frequency and
> vascular resistance
> > constitute compensatory 
> > mechanisms for blood pressure. We also know that
> > hypotension is often a late 
> > sign and that patients are always hemodynamically
> > stable until they become 
> > unstable.
> > 
> > 
> > 
> > For years our lecturers have warned about the
> > existence of compensated 
> > shock, occult hypoperfusion and sudden
> > decompensation. It is curious that 
> > two large retrospective studies found that
> > approximately 1/3 of patients 
> > presented relative bradycardia and had better
> > survival. This raises various 
> > questions.
> > 
> > 
> > 
> > I think that no particular age avoids:
> > 
> >   1.. Increased intravascular pressure produces
> > increased uncontrolled 
> > bleeding and clot disruption.
> >   2.. The dose-dependent damaging effects of
> > isotonic fluid administration.
> > What level of evidence is there in favor of
> > normalizing blood pressure in 
> > children aged 6-8 years who present uncontrolled
> > hemorrhage? What level of 
> > evidence is there to indicate the use of 20 ml/kg
> > isotonic boluses? 
> > According to my review of the literature, the
> > evidence is scarce.
> > 
> > 
> > 
> > It would be a pleasure to hear your opinions on
> > this.
> > 
> > 
> > 
> > 
> > 
> > Thank you,
> > 
> > 
> > 
> > 
> > 
> > J SuÃ¡rez PelÃ¡ez.
> > 
> > 
> > 
> > 
> > 
> > 
> > 
> > ----- Original Message ----- 
> > From: <tch at sun.ac.za>
> > To: "Trauma & Critical Care mailing list"
> > <trauma-list at trauma.org>
> > Sent: Wednesday, June 13, 2007 4:58 PM
> > Subject: RE: Pre-hospital fluid therapy.
> > 
> > 
> > Jose
> > 
> > I do have a concern about this concept in the
> > younger child - under age 6-8, 
> > as their physiology IS different. The compensate
> by
> > progressive tachycardia 
> > and maintain SBP till just too late - then drop
> off
> > over the waterfall and 
> > DIE on you!
> > 
> > For adolescents or adults I agree completely
> > 
> > Tim
> > Dr T C Hardcastle
> > M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> > Senior Surgeon / Senior Lecturer: Surgery (Trauma
> > and ICU)
> > ATLS  instructor and DSTC Cape Town Course
> Director
> > Intern program Coordinator: Surgery
> > M.Med (Emergency Medicine) Executive Committee
> > member
> > Clinical Head (Director): Diana Princess of Wales
> > Trauma Unit
> > Division of Surgery (General) Room 4064
> > Department of Surgical Sciences
> > Tygerberg Hospital / University of Stellenbosch
> > PO Box 19063
> > Tygerberg 7505
> > Western Cape
> > South Africa
> > e-mail: tch at sun.ac.za 
> > Cell: +27824681615
> > Office: +27219389281 or 4911 pager 0302
> > 
> > 
> > 
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org 
> > [mailto:trauma-list-bounces at trauma.org]On Behalf
> Of
> > JOSE SUAREZ PELAEZ
> > Sent: Wednesday, June 13, 2007 5:25 PM
> > To: Trauma & Critical Care mailing list
> > Subject: Re: Pre-hospital fluid therapy.
> > 
> > 
> > Dear Dr. Mattox,
> > 
> > 
> > 
> > Thank you for your comments. The objective of my
> > email was to hear different
> > opinions from colleagues on certain issues.
> > 
> > 
> > 
> > I believe that while SBP continues to be used as
> the
> > main therapeutic
> > objective in bleeding patients, while the
> > means/devices to measure SBP are
> > maintained and not replaced/complemented by other
> > more sensitive measures
> > (SLCO2, NIRS, etc) to detect acceptable perfusion
> > indicating
> > non-administration of fluids (to avoid greater
> > hemorhage, re-bleeding and/or
> > a systemic inflammatory response due to
> unnecessary
> > fluid administration),
> > SBP will continue to constitute the golden
> objective
> > in pre-hospital
> > treatment and set back the day when bleeding
> > patients are not given
> > excessive quantities of fluid that may result in
> > devastating consequences,
> > whether immediate or not.
> > 
> > 
> > 
> > You and other experts have warned about the
> > limitations of SBP as
> > therapeutic objective and have proposed the use of
> > permissive hypotension.
> > However, quantities of isotonic fluids >750 ml may
> > continue to be
> > administered. I think the didactic use of the
> > concept permissive hypovolemia
> > (and not hypotension) might help to reduce excessi
> ve
> > administration of
> > fluids: attempting to provide each patient with
> only
> > what he/she needs,
> > specially in children.
> > 
> > 
> > 
> > There are sufficient arguments against the need to
> > normalise BP in bleeding
> > patients. I think the scientific community is
> > tending towards this
> > viewpoint.  But how to ensure the administration
> of
> > the necessary fluid to
> > achieve a balance between damage and benefit? As
> the
> > Dutton study has shown,
> > this is complicated.
> > 
> > 
> > 
> > Perhaps, as you propose, 50 ml boluses using
> radial
> > pulse and state of
> > consciousness as endpoints, regardless of BP,
> could
> > prevent situation like
> > following: my nurse ToÃ±i usually has BP of 70, in
> > the event of an accident,
> > she could be hypotensive, tachycardic, anxious,
> etc,
> > so, she would probably
> > receive excessive fluid possibly causing increased
> > bleeding, re-bleeding,
> > iatrogenic respiratory distress, or even
> multi-organ
> > failure and death,
> > after hemorhage control and a "normal" BP.
> > 
> > 
> > 
> > Therefore I believe we should start to use the
> term
> > Permissive Hypovolemia,
> > not merely for semantic reasons but because of its
> > conceptual and didactic
> > usefulness.
> > 
> > 
> > 
> > I would be grateful for any comments you may have
> > (pro or cons)
> > 
> > 
> > 
> > 
> > 
> > JosÃ© Suarez-PelÃ¡ez
> > 
> > 
> > 
> > 
> > 
> > 
> > ----- Original Message----- 
> > From: <KMATTOX at aol.com>
> > To: <trauma-list at trauma.org>
> > Sent: Tuesday, June 05, 2007 12:09 PM
> > Subject: Re: Pre-hospital fluid therapy.
> > 
> > 
> > 
> > In a message dated 6/5/2007 5:27:34 A.M. Central
> > Daylight Time,
> > josuarez at teleline.es writes:
> > 
> > JosÃ©  Suarez-PelÃ¡ez
> > 
> > 
> > 
> > Dr.  Jose Suarez-Pelaez has asked this group to
> > respond to an article  and a
> > letter to the editor in the journal, "Injury."   
> > The  letter contains some
> > germane observations and questions.   
> Particularly,
> > the question of the
> > value
> > of systemic blood pressure as a measure  of
> adequacy
> > of resuscitation,
> > perfusion, etc. is right on.     However, for the
> > majority of the world,
> > this readily
> > available device is what is  available, and Near
> > Infrared Spectroscopy has
> > not
> > yet been  standardized.
> > 
> > I would agree that in the referenced study, the
> > inclusion criteria are two
> > broad and using a BP of 90/- systolic, or better
> > 70/- as an entry criteria
> > for
> > such studies would be more appropriate.
> > 
> > K Mattox
> > 
> > 
> > 
> > ************************************** See what's
> > free at
> > http://www.aol.com.
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/ 
> > 
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/ 
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/ 
> > 
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/ 
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/ 
> > 
> 
> 
> Sanjay Gupta MD
> Tel: 412 335 6304
> 
> 
>        
>
____________________________________________________________________________________
> Moody friends. Drama queens. Your life? Nope! -
> their life, your story.
> Play Sims Stories at Yahoo! Games.
> http://sims.yahoo.com/  
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> Confidentiality Notice
> 
> This e-mail message, including any attachments, is
> for the sole use of
> the intended recipient(s) and may contain
> confidential or proprietary
> information which is legally privileged.  Any
> unauthorized review, use,
> disclosure, or distribution is prohibited.  If you
> are not the intended
> recipient, please promptly contact the sender by
> reply e-mail and
> destroy all copies of the original message.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 

Sanjay Gupta MD
Tel: 412 335 6304

____________________________________________________________________________________
No need to miss a message. Get email on-the-go 
with Yahoo! Mail for Mobile. Get started.
http://mobile.yahoo.com/mail 

List Archives

For your convenience, find the Trauma List Archive Below

Carotid artery dissection